December 2011 (Part 1)

By Tarik Afnoukh, OREXer ’11-12

I started my day by Dr. Harken morning lecture. The topic was about how to take the best therapeutic decision to treat a 60-years-old man, who had recently an antero-septal myocardial infarction (probably the ECG showed the q waves in V1, V2, by proximal occlusion of left anterior descending coronary artery) and colon cancer with liver metastasis. Dr. Harken was asking the residents on how they might take in charge the situation as if the patient is in the unit. He was making the case more and more difficult in changing the diagnosis from simple superficial liver metastasis (which can be accessible surgically) to profound metastasis (not easily accessible).

Then he stated to manage the patient’s heart problem secondary to the MI. Antero-septal ischemia is usually associated with decrease cardiac output by either perforation of the ventricular septum (the wall between two ventricles) or by acute Aortic or Mitral valve insufficiency which can cause the decrease of blood supply to the heart. To improve the patient’s heart perfusion (Oxygen), we need to increase the diastolic pressure of the Aorta to let blood pass to the coronary arteries which are originate from the beginning of the Aorta (immediately above the aortic valve). Most residents were agreed with the use of Intra-aortic Balloon Pump (IABP), it is a mechanical device that we introduce to the aorta through the femoral artery. The balloon is connected to the machine which measure the variation between systolic and diastolic pressure, then the balloon will be inflated by a gas (helium) in the diastolic time to push the blood back to the heart; because the aortic valve is closed in diastolic (not totally if insufficiency), the blood will pass to the coronary arteries increasing the heart oxygenation and alleviating myocardial damage and the patient’s pain. Unfortunately, when the balloon is deflated the blood pressure drops down because there is more space for the blood to fill the Aorta, and the risk of bowel ischemia or kidney infarction is high if we let the balloon in place for a long time.

I walked  to the OR after that at around 8.15A.M. I was with Dr. Sadjadi (Surgeon), Dr. Chuang, and Dr. Lesher (Residents). Mrs. A. R a 64-years-old female  diagnosed with rectal cancer was the first patient. She was, unfortunately, the disease is closer to the anal canal (anus) which is the indication of anterior peritoneal resection. It does mean the surgeon needs to remove the tumor (rectum) but also the anus because he cannot attach the descending colon to the anal sphincter touched by the cancer. It is really hard for Mrs. A to take such decision to be in the OR; she will never be able to use the bath room for defecation as usually, but she will have grooming in her abdomen into a small bag stuck to her skin. After intubation and placing the sterile field, a large incision made in her abdomen bellow the umbilicus and a bit above it.  This   surgery   has  two  times.

First time, Dr. Sadjadi started to guide the resident Dr. Chuang how to dissect the sigmoid colon from the fascia that handles it to the abdominal wall. They were able to palpate the tumor, it was hard and huge. After that Dr. Sadjadi was dissecting the tissues surrounding the tumor meticulously to avoid injuring other organs like vagina, bladder, and the most important the ureter which can cause big problems in the following up with the patient after surgery (like kidney failure secondary to obstruction of the ureter by sclerosis from the surgical trauma). He was time to time checking with the anesthesiologist about the color of  the  patient’s  urine  (if  trauma, we  might  see  the  blood in  the  urine  collector).

I  wasn’t  able  to  see  what  was  going  on  because   the   surgeons  were working in a very narrow area (pelvic), I used that time to talk to the circulator Mrs. Marilyn. She is an awesome travel nurse retired from Kaiser years ago, she looks young but she has three kids; one is an Allergologist in New-York city, one is a Neurologist in SF, and one is a Financial specialist in Chicago. She explained to me what does mean travel nurse and how they work with different hospitals in different places; that’s kind of amazing retirement job.

The  second  time  of  Mrs. A  surgery  was  the  perineum  time or anal time. Dr. Sadjadi made an incision around the anus then dissected it slowly from the lower pelvic tissues until he felt the fingers of the resident who was an abdominal guide to him. Fortunately there were no extension of the tumor to the vagina; the dissection was easy and successful. Dr. Sadjadi then closed definitively the patient’s anus, and ordered the resident to fix the end part of the colon to the patient’s abdominal wall in about 3cm from the midline incision. Mrs. A was transferred then to the ICU for more assistance.                                                                                              .

Second patient of my surgery day was, Mr. K. J a 23-years-old man who was shot one month ago in the abdomen, leg, and chest. The chest projectile caused for him a pneumothorax (air in the chest cavity, outside the lung). He received a chest tube immediately after his admission to the hospital but it didn’t help him a lot. To prevent the recurrence of pneumothorax; VATS Pleurodesis was the best therapeutic indication for him. It means Video-Assisted-Thoracoscopy-Surgery, and pleurodesis is the dissection of all adhesions that had been created between the lung and the chest wall after the accident; in doing that the adhesions will bleed which can help to create a fibrotic tissue between the lung and the inside wall of the chest closing the pleural cavity to prevent the lung to collapse again.

First, to put the instrument in the chest we need to collapse one lung because there is not free space in the chest like as it is in the abdominal cavity (Laparoscopy). The anesthesiologist intubated the patient and inflated a balloon in the right main bronchi to collapse the right lung (guided by a bronchoscope). After that, Dr. Chuang guided by Dr. Sadjadi introduced a camera through the hole of the chest tube that Mr. J had before, and made another hole guided by the camera to introduce a necessary device to dissect the adhesions. Because the camera was in the chest cavity, we saw the heart and the mediastinum vessels. The surgery was easy with the camera, and the patient transferred after that to the post-op for further support.

It was my best day in the OR for now because Mr. J heart’s was the first American heart I saw in my career!  I’m hopping for both patients a quick recovery.

I  am  wishing  for  all  OREX’s  members,  all  Highland  Hospital Surgery team  especially  Dr. Harken a happy, healthy, and a successful new year 2012.     Thank you for such great opportunity

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Posted on May 14, 2012, in Entries and tagged , , , , , . Bookmark the permalink. Leave a comment.

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